A Child in PICU requires RRT – what should I choose between HD, CRRT or PD Join us for a ward round Mignon McCulloch – Cape Town, South Africa Michael Zappitelli – Montreal, Canada Rupesh Raina – Cleveland, USA

Case 1

9 year old girl Wt 20kg Ht 120cm Presents with large neck mass extending into the chest Biopsy – Hodgkins Lymphoma U/S shows big bulky kidneys of 12cm – infiltration? Blood results: Hb 7g/dl WCC 15 x 10 9 /l Platelets 400 x 10 9 /l Na 139mmol/l K 5.8mmol/l Urea 9.5mmol/l Creatinine 120umol/l PO4 2.5mmol/l LDH 900mmol/l Uric acid 0.7mmol/l Schwartz Ht x 40/Creat = 40ml/min/1.73m 2

Tumour Lysis Syndrome Prehydration and Allopurinol started Rasburicase not available(Recombinant urate oxidase) Chemotherapy started next morning Bloods 12hrs later: K 7.8 Urea 25 Creat 250 Po4 4.5 Currently incidence for Burkitts Lymphoma for Every 1 case/year seen in London, Will see 10 cases/year in Cape Town and 50 cases/year in Tanzania

What form of dialysis would you do in? Dar es Salaam, Tanzania Cape Town, South Africa London, UK

What form of dialysis would you do in? Dar es Salaam, Tanzania Only available dialysis – Manual PD Possibly using Ringer’s Lactate + Dextrose And a Chest drain… Cape Town, South Africa Haemodialysis +/- CVVHDF London, UK Nil as would have given Rasburicase

Case 2

Case of AKI during ECMO Newborn (G1P0, diabetic mother, PROM, 36 weeks GA, BW 3.5 kg) Severe HIE, intubated at birth, cardiopulmonary arrest, renal function appears okay. ECMO DOL 3; duration 5 days. Day 4 ECMO, SCr doubles, then triples. UO drops, progressive fluid overload

Severe fluid overload: wt 5kg ECMO day 4: inline hemofilter for SCUF ECMO day 5 (DOL 7): decannulation planned. Nephrology consulted. HD line inserted at ECMO cannula site. DOL 8: wt 5.3 kg. DIC picture, UO very BP dependent. High dose Lasix, metolazone and spiro started. TFI only ~30% 5 days later: CRRT, fluid removed successfully over 1 week.

Decision 1: SCUF vs other RRT on ECMO? SCUF: only fluid removal. Electrolyte disorder concern Rely on accuracy of IV pumps Easy, cheaper, quite effective PD: severe edema: leak. Need earlier. ?less accurate/consistent? Easy, cheap, can be quite effective, physiologic solution CRRT: complexity, expense, complexity Accurate, physiologic solution

Decision 2: HD catheter vs PD at ECMO end? HD catheter: ECMO site? New site? access use; technical issues possibility to save an access, CRRT PD: would have needed to put in sooner possible long term use; save access will it really definitely give you what you need right now?

Case 3